October 24, 2018

Study Finds Gap in Quality and Safety Competencies Based on Level of Education

Nurses with bachelor’s degrees report being very prepared in more quality and safety measures than do their peers with associate degrees, finds a new study by researchers at NYU Rory Meyers College of Nursing.

In 2010, the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) published “The Future of Nursing: Leading Change, Advancing Health.” The milestone report provided recommendations for how nurses can best advance the nation’s health and meet the increased demand for care. The report calls for an increase in the proportion of nurses with bachelor's degrees to 80 percent by 2020—a recommendation supported by studies showing that nurses with bachelor’s degrees have better patient outcomes, including lower mortality rates.

“The evidence linking better outcomes to a higher percentage of baccalaureate-prepared nurses has been growing. However, our data reveal a potential underlying mechanism—the quality and safety education gap—which might be influencing the relationship between more education and better care,” said Maja Djukic, PhD, RN, associate professor at NYU Meyers and the study’s lead author.

“Understanding the mechanisms influencing the association between educational level of nurses and patient outcomes is important because it provides an opportunity to intervene through changes in accreditation, licensing, and curriculum.”

A nursing workforce that is well-prepared in quality and safety competencies is critical for delivering high-quality and safe patient care. However, a previous study led by NYU Meyers’ Christine Kovner, PhD, RN, FAAN, identified gaps in quality and safety education between associate- and baccalaureate-prepared nurses who graduated between 2004 and 2005.

In their new study, the researchers—Djukic, Kovner, and NYU Meyers’ Amy Witkoski Stimpfel, PhD, RN—examined quality and safety preparedness in two additional cohorts of new nurses who graduated with either associate or bachelor’s degrees in 2007-2008 and 2014-2015. They surveyed more than a thousand new nurses (324 graduating 2007-2008 and 803 graduating 2014-2015) from 13 states and the District of Columbia, asking how prepared they felt about different quality improvement and safety topics. They then analyzed the differences in responses between nurses with associate and bachelor's degrees.

The researchers found significant improvements across key quality and safety competencies for new nurses from 2007 to 2015, but the number of preparedness gaps between bachelor's and associate degree nurse graduates more than doubled during this timeframe.

In the 2007-2008 cohort, nurses with bachelor's degrees reported being significantly better prepared than nurses with associate degrees in five of 16 topics: evidence-based practice, data analysis, use of quality improvement data analysis and project monitoring tools, measuring resulting changes from implemented improvements, and repeating four quality improvement steps until the desired outcome is achieved.

For those graduating in 2014-2015, nurses with bachelor's degrees reported being significantly better prepared than associate degree nurses in 12 of 16 topics: the same five topics as the earlier cohort as well as data collection, flowcharting, project implementation, measuring current performance, assessing gaps in current practice, applying tools and methods to improve performance, and monitoring sustainability of changes.

The researchers note that laws and organizational policies encouraging or requiring bachelor’s degrees for all nurses could close quality and safety education gaps. For example, New York State recently passed a law—the first in the country—requiring future new nurses to obtain their bachelor's degree within 10 years of initial licensure. Employers can also effect change by preferentially hiring nurses with bachelor’s degrees, requiring a percentage of the nurse workforce to have a bachelor’s degree, or requiring nurses with associate degrees to obtain a bachelor’s within a certain timeframe as a condition of keeping their employment.

The study was funded in part by the Robert Wood Johnson Foundation and the National Council of State Boards of Nursing Center for Regulatory Excellence.